Applicantswill Not Be Considered Unless This Form Is Completed in Full

DEANSGATE

21 HERPO ROAD CRAIGHALL PARK 2196
TELEPHONE (011) 788 0704 | FAX: (011) 880 0803
(WO) FUND RAISING AUTHORITY 01-100318-000-2

APPLICATION FORM

APPLICANTSWILL NOT BE CONSIDERED UNLESS THIS FORM IS COMPLETED IN FULL.

IN ORDER TO REMAIN ON THE WAITING LIST CONFIRMATION MUST BE RECEIVED ANNUALLY BY 31ST JANUARY. PLEASE ADVISE OF ANY CHANGE IN THE DETAILS SUPPLIED BELOW.

SURNAME:______

CHRISTIAN NAMES: MR ______

MRS/MISS/MS ______

DATE OF BIRTH: MR______ID ______

DATE OF BIRTH: MRS/MISS/MS______ID ______

RESIDENTIAL ADDRESS: ______CODE______

POSTAL ADDRESS: ______

TELEPHONE NUMBERS: (H)______W______

(CELL)______

(e-mail)______

MARITAL STATUS: MARRIED WIDOWED DIVORCED SINGLE

NATIONALITY:______

RELIGION :______

CHURCH YOU ARE PRESENTLY ATTENDING: ______

OCCUPTION BEFORE RETIREMENT: MR______

MRS______

HOBBIES AND SPECIAL INTERESTS MR______

MRS______

NAME OR OTHER HOME THAT YOU HAVE LIVED IN______

REASON FOR LEAVING______

TYPE OF ACCOMODATION REQUIRED (MARK WITH AN X)

FRAIL CARE:PRIVATE______SHARING______

MIDCARE______

HIGH CARE UNIT (ALZHEIMER WING: ______

PURCHASE ON LIFE RIGHTS ONE BEDROOM COTTAGE: ______

PURCHASE ON LIFE RIGHTSTWO BEDROOM COTTAGE: ______

NAMES AND ADDRESSES OF CHILDREN/NEAREST RELATION/OR FRIEND

______TEL. NO. ______

N.B. A medical examination will be required before admission and a Deansgate medical form must be completed by the doctor. Admission is subject to the admission requirements PERSONS WITH ALZHEIMERS.

It is a condition of residence in the main building that all prescribed medicines are to be administered by the Sister on duty.

All applicants will be subject to strict screening as required by the Welfare Department.

A passport size photograph must be submitted ON ADMISSION.

INCOME

WELFARE PENSION NO. ______R ______Per Month

OTHER SOURCES OF INCOME ______R ______Per Month

SUPPORT FROM RELATIVES ______R ______Per Month

TOTAL R ______

SAVINGS INVESTMENTS OR OTHER CAPITAL R ______

DO YOU OWN YOUR OWN PROPERTY ______R______

Will you be able to pay Deansgate the full monthly rentals including the increases annually------

DECLARATION

I hereby declare to abide by all rules and regulations of the home as laid down by the Committee.
I understand that the Committee reserves the right to move me to more suitable accommodation or give me thirty (30) days’ notice to leave the home without having to give any reason for so doing.
I understand that rental is payable monthly in advance and the amount will be determined when admission is granted and will be reviewed annually. I also understand that rental will increase on the 1stApril each year at the discretion of the executive committee.
I undertake (and authorize my estate) on my death, to pay any difference due between the amount paid and the full economic charge for board and lodging if it is found that I have not correctly disclosed my income. This includes any subsequent income or assets since my admission.
I undertake to sign an annual declaration to the effect that there has been no material change in my income/assets since my admission.
I hereby give permission for a copy of my will to be sent to Deansgate on my death.

SIGNATURE OF APPLICANT ______

WITNESS ______DATE ______

ADMISSION AUTHORISED ______DATE ______

Correspondence should be addressed to:

The General Manager and Health Director Deansgate

21 Herpo Road
Craighall Park

2196

Tel: 011 788 0704/5

Fax: 011 – 880 0803

Email: